Form Eta-9061 - Individual Characteristics Form Work Opportunity Tax Credit And Welfare-To-Work Tax Credits 2004

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U.S. Department of Labor
Individual Characteristics Form
Employment and Training Administration
Work Opportunity Tax Credit and Welfare-to-Work Tax Credits
1. CONTROL NO.
Individual Information
2. DATE RECEIVED
(
(Instructions on the Back)
(For Agency Use Only)
For Agency Use Only)
OMB Control No.: 1205-0371
(Rev. July 2002)
3. EMPLOYER NAME/ADDRESS
4. EMPLOYER FEIN
5. EMPLOYMENT START DATE:
__________________________
Starting
6. Have you worked for the
above employer before?
Wage: $__________ per hour
Job Title:_________________
Yes
No
8. SOCIAL SECURITY NUMBER:
7. NAME OF INDIVIDUAL (Last, First, Middle)
THE ABOVE NAMED INDIVIDUAL IS DETERMINED AS HAVING THE FOLLOWING CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION.
10. Is a veteran and a member of a
9. Is your age between 16 - 25?
11. Is a member of a family that received TANF benefits
family that received Food Stamps for
for any 9 months in the last 18 months?
Yes _______
No _______
a period of at least 3 months in the
Yes _______
No _______
last 15 months?
If YES, indicate your “Date of Birth” below:
If YES, also complete Box 17.
Yes _______
No _______
Date of Birth:
If YES, also complete Box 17.
12. Is a member of a family that received
13. In the past year has been
14. Lives and plans to continue living in a Federal Em-
Food Stamps for the last 6 months?
convicted of a felony or released from
powerment Zone, Enterprise or Renewal Community?
prison after a felony conviction?
Yes _______
No _______
Yes _______
No _______
Yes _______
No _______
or . . .
16. Received Supplemental Security Income (SSI)
If Yes, complete below:
benefits for any month ending within the last 60 days.
for at least a 3-month period within the last 5
Date of Conviction ______________
Yes _______
No _______
months, BUT is no longer receiving them?
Date of Release ________________
Yes _______
No _______
17. If individual is not a primary recipient of benefits,
Total income for the past 6 months
If YES to either, also complete Box 17.
please provide the following:
prior to hire date for all family members
living in the same household:
___________________________________________
Name of Primary Recipient
Total Income: $ _________________
15. Is receiving or has received Rehabilitation
(If no income, enter “0” above)
___________________________________________
Services through a State Rehabilitation
Address of Primary Recipient
Services program or the Veterans’ Administra-
Number of family members living in
tion?
the same household for the past 6
Have you lived with this person for the last 6 months
months prior to hire date, including
from hire date?
Yes _______
No _______
yourself:
Yes _______
No _______
______________
If no, list dates and addresses where you lived for the
last 6 months in Box 19.
This section is to be completed by individuals starting work after December 31, 1997 under the Welfare-to-Work Tax Credit only.
18. Is a member of a family that:
• Has received TANF payments for at least the last 18 consecutive months .................................... Yes ____
No ____ or
• Has received/is receiving TANF payments for any 18 months starting
after August 5, 1997; and the earliest 18-month period beginning after August 5, 1997
ended within the last 2 years; or ..................................................................................................... Yes ____
No ____ or
• Stopped being eligible for TANF payments within the last 2 years because Federal or
state law limited the maximum time those payments could be made .............................................. Yes ____
No ____
19. SOURCES USED TO DOCUMENT ELIGIBILITY:
NOTE: I certify that the information is true and correct to the best of my knowledge. I understand that the information above may be subject to
verification. The signature of the party completing this form is required below.
20. SIGNATURE:
21. DATE COMPLETED FORM:
Page 1 of 3
ETA-9061 (Rev. August 2004 – Mich. Reprint)

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